The insurer says the hospital must appeal and the hospital says the insurer must fix it. Who files?
You can always file a member appeal yourself, in your own name, on any denial of your claim; the provider's appeal is a separate right and neither depends on the other. Ask the insurer for the written denial with the reason and provision, file the member appeal within the deadline, and ask the hospital in writing to send its records and a reconsideration on the same claim.
What to do, in order
- Step 1
Get the denial in writing
Ask the insurer for the Explanation of Benefits or denial letter for the claim, with the reason code and the plan provision. A phone explanation is not a determination and cannot be appealed.
- Step 2
File the member appeal
Every plan must give members an internal appeal on an adverse benefit determination. File it in writing with the claim number, what you are asking for, and the documents. Do not wait for the hospital.
- Step 3
Ask the hospital in writing for two things
The itemised claim as billed and the medical records, and a corrected claim or reconsideration on their side if the denial is a billing or coding reason. Billing offices file reconsiderations every day; "we cannot appeal unless the insurer tells us to" is not correct.
- Step 4
Name the parties in the appeal
If the insurer says only the provider can act, quote it and ask the insurer to state the provision that prevents the member's appeal. There is none. That sentence tends to end the loop.
The deadline that applies
At least 180 days from the denial notice to file the member appeal on ERISA and ACA plans (29 CFR 2560.503-1; 45 CFR 147.136); provider appeal windows are set by contract and are often shorter, so the member appeal protects the claim. The letter controls.
Calculate your date →Documents to gather
- The EOB or denial letter with the reason code
- The itemised claim as billed
- The medical records for the visit
- Any written statement from either party that the other must act
Go deeper
Related questions
Can I appoint someone to appeal for me?
Yes. Plans accept a signed authorized-representative form, and the provider can be that representative if you choose.
What if the denial is a coding error?
The provider files the corrected claim; your member appeal keeps the deadline alive and asks the insurer to reprocess once it arrives.
Do I have to pay the hospital in the meantime?
Ask the billing office in writing to hold the account pending the appeal. Most do once an appeal is filed.
Sources
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